Surviving
the
streets

EI Gato is a fifteen year old who has lived on the streets of a large Latin
American city since the age of
eight. He has been imprisoned five
times, hospitalised twice, and forced to
live in institutions for abandoned or
'delinquent' children. He visits his
mother every three or four months and
occasionally stays with her during public holidays. For the past three years he has
regularly sold sexual favours to adults to survive. Living on the streets has exposed him to scabies, lice, fleas,
conjunctivitis, impetigo, amoebic dysentery, giardiasis, ascaris and
gonorrhoea.
More recently, he was infected with HIV (the virus that causes AIDS).

Millions of children and adolescents
work and live on the streets of the world's
cities; begging at crowded intersections,
shining shoes, working as parking boys,
selling newspapers, or stealing from
market stalls. At night they sleep on the
pavement or under park benches. These
children are often seen as a threat to
society or an embarrassment to governments.
Denied affection, education and
help, they are often abused by others, imprisoned and even - as in Brazil -
murdered
by squads hired to rid the
streets of 'pests,' believed to be a threat
to the tourist industry. They survive
through experience and gather together
in gangs to create a family and support
structure. They see adults as their enemy
and most fear and hate the police.

'Survival sex', international sex
tourism and sexual abuse affect the lives
of millions of children living in poverty
worldwide. Children often become
victims of adult sexual exploitation and
are sexually active amongst themselves.
Since street children are therefore at
increasing risk from HIV, they have
recently become a subject of concern to
AIDS educators.

But as more street children become
infected with HIV, they may suffer even
more discrimination. A doctor attending
children in one of Brazil's largest state
reformatories admitted: 'When a child
tests HIV positive, I tell them "Prepare
to die. You are going to die, you have
AIDS." We expel them. We cannot keep
them here.' Not only is it cruel and
misleading to tell a child with HIV that
s/he is going to die (the child may remain
healthy for many years), throwing them
back on the street with a 'death
sentence', and without ongoing support,
is totally inhumane.

The lifestyles of these children lead to
greater than average health problems.
In addition to the illnesses suffered by EI Gato, living on the street means a higher
risk of injury from traffic accidents, burns,
lacerations, and violence-related
trauma. Drug use is endemic. In
developing countries this usually
involves sniffing glue, gasoline and paint thinner. These poisonous substances -
which
affect health and behaviour - are
accessible and inexpensive. In
Tegucigalpa, Rio de Janeiro, Calcutta or
Manila a 'high' can be maintained for an
entire day with a forty-cent plastic bag of
shoe cement

In most cities these children cannot
get treatment for their health problems
because they do not have identification
papers, or a permanent address, are not
accompanied by an adult, or are simply
unable to pay for treatment. They avoid
visiting clinics and hospitals because
they fear questioning by police, doctors
and nurses.

Very little information is available on
the lifestyles, health and rate of HIV infection
among street children, although
isolated studies indicate HIV is a
problem. But, as with other sectors of
society, the time to start preventing
further spread of HIV is now. Community
outreach workers, health promoters and
street educators should work together to
develop appropriate methods of health
education and improve access to
existing health services. Educating street
educators and street leaders, so that
they can become street-based health
promoters, is of central importance.

Health and family planning professionals
and street project workers must
begin to work together, finding ways of
working with children, not over and
above them. Simply 'clearing' the streets
by placing children in institutions is not
the answer. Behavioural change can
only come from promoting self-worth
and creating an environment where
children can make informed choices.
Children, on and off the streets, need to
feel good about themselves, earn
money, have fun, and have the opportunity
to study and work in dignified employment

For those who have never worked with
street children, the guidelines on pages 2-3 give some practical ideas about
where to start. But the children
themselves are the experts: they know
what their concerns are and how they
see their own future. Unless these concerns
are listened to and addressed, no
street child will listen to warnings about
AIDS.

Beyond meeting immediate health needs, the broader issue of why children
are living on the streets in the first place
needs to be addressed. The threat of
AIDS and other sexually transmitted
diseases, or the increase in drug addiction,
cannot be separated from lack of
choice and opportunity.

By the end of this century, many
former street children will be living in
slums and shanty towns, prison cells
and working class neighbourhoods.
Many of today's street children,
including EI Gato, may be living with
AIDS. We must try to ensure that he, and
others like him, do not die without
humane care and support; that others
protect themselves from becoming
infected with HIV in the first place. And
with a broader vision, we can work to
reduce the numbers of those forced to
live on the streets through poverty,
homelessness or war.

News

First International Conference on
AIDS and Homeless Youth: an agenda
for the future
Held June 25 1990, San Francisco,
USA.
'I am pleased you are all here talking about
AIDS and street children and thinking of ways
to educate us. But there is a problem. We often do not listen to what most adults tell us.'

These were the words of Byron Gomez, a 16
year old living on the streets of Guatemala
City who spoke during one of the final working
sessions at the above conference. It was
a timely reminder to participants that the aim
should be to take action with children, not just
for them. Youths themselves need the opportunity
to lead in the development of creative
programmes for their peers. This first international
conference on AIDS and homeless
youth brought together participants from 27
countries, including clinicians, policy makers, researchers and youth workers, to discuss
ways of working together on a broad set of
issues.

Knowing where to start

Dr Judith Ennew from Streetwise International
provides some practical advice for AIDS educators and others planning to work with street children

There are three basic principles to
remember when planning educational
programmes with children who survive
on the streets:

the main obstacle to successful programmes
is our own attitudes;

the main resource in any programme
is the children themselves;

AIDS education can only succeed in
the context of overall personal
development: you cannot expect
children to protect themselves if they have no sense of their own worth.

Start with yourself

Examine your own, and your
society's, attitudes and prejudices
towards street children, their sexual
and other behaviour and AIDS. What
do your colleagues believe and say
about these children?

Find out what the children think and
believe about themselves! Don't be
afraid of approaching the children: it's
OK to say 'hello.'

Recognise that sexual intercourse
takes place between children, as well
as in the sexual exploitation of
children by adults. Be aware that
sexual abuse takes place in families,
orphanages and prisons. Do not
deny the children's sexuality or sexual
experience, or lower their self-image,
by making them feel 'bad'
because they earn money by prostitution
or engage in homosexual
relationships.

Beware of creating special groups.
For example, many projects make
the mistake of separating girls out
from the boys, giving food, shelter
and clothing only to the girls. This
encourages female dependency. If
you make differences between
groups of children you must have
good reasons for doing so. Discuss
these with the children.

Remember that street children
should not be seen as passive recipients of care. They are survivors in
their own right and must be
respected as such.

Beware of creating dependency.
Most projects start with the idea of
providing food or shelter. You do not
have to give food unless children are
hungry, and they may have no need
for special buildings. As one project director, Fabio Dallape, points out: 'Be cautious in presenting yourself as Father Christmas with your hands full of gifts. Nothing is free in
life and the children know it. Do not
put them in a world of dreams' [your
dreams].

Finally, examine your motivation for
working with street children, as well
as that of other volunteers. Avoid
allowing the vulnerability of these
children to satisfy the emotional
needs of the adults concerned.

Remember that the children
themselves are the main resource.
Programme staff must get to know
and understand them.

Use the children themselves as
educators. Identify the 'gang'
leaders, or street educators who
have often spent years on the
streets themselves. Don't assume
that you must start with videos and
comics because children enjoy
these. Personal contact is the best
way for messages to be passed on
and remembered. People of all ages
who are not accustomed to learning
with posters, books and videos
often have a different perception
of two-dimensional media. If you
want to use video, or slides, why
not make your own with the
children?

You do not need vast amounts of
money or large, purpose-built
premises to start up a local
programme. Use existing local
resources (a church-run day
centre?) and involve families and
communities. Some organisations
may be willing to provide resources
or funding e.g. medical associations,
business community or the
national Red Cross.

Share resources and experiences
with other projects. Children have a
range of problems and require a
range of services. Many of these
services already exist. The problem
may be one of access. Sometimes
street children are chased away
from hospitals and clinics because
of their bad reputation. Avoid
providing parallel services, but try to ease access to, and delivery of,
existing services. This will often
involve adapting existing services
and working to change the attitudes
of staff

Pass on your own experience of
working with street children to other
health professionals and educators.

Brazil

Developing materials
The Brazilian Interdisciplinary AIDS
Association (ABIA) has produced an
educational pack on AIDS/HIV for
street children, including a video, cartoon
book, tape slide show, and
educator's guide. Excellent, colourful
drawings tell the story of 16 year
old Joni, who lives on the streets of
Rio de Janeiro.

When Joni becomes
worried about a new disease called
AIDS he talks to his friends, and to
a local prostitute and transvestite.
The material includes clear and
imaginative discussion about safer
ways of having sex, and how to clean
a used needle when injecting drugs.
The conversational language was
carefully pre-tested with street
children, who also came up with the
idea of Joni asking for advice from a
transvestite.

The educator's guide explains the use of language in the
materials, and provides a useful background for starting
discussions on sexuality and sexually transmitted diseases. A
consortium of organisations working with street youth has been set
up to develop additional training activities and materials.

Work towards improving the general
health and self image of the
children. Like most children living in
poverty, their health will already be
poor. Giving them the knowledge
and the facilities to improve this will
increase their self respect, as well
as help resistance to infection
and/or the development of AIDS.

Discuss safer sex in the context of
the children's other concerns, such
as broader health issues, personal
safety, economic survival, job skills,
legal and other rights, housing, drug
taking and so on.

When you encourage condom use
in sexual relationships, emphasise
that this applies to sexual contact
with friends as well as with
adults/clients/strangers.

Help the children gain access to
condoms and teach them how to
use them. Showing a picture of a
penis gives very little idea to a child
who may not identify with body parts
drawn in outline, especially if the
rest of the body is not drawn.
Discussion and practical
demonstration, using a banana or
piece of wood carved to look like a
penis, works much better. Allow the
children to play with condoms and become familiar with them. They
might blow them up as balloons!
Turn their play into education.

Be prepared to discuss anal
intercourse with all the children,
not just the boys. There is widespread
evidence that girls practice
anal intercourse to avoid
pregnancy. Bring topics like this into
the general discussion of sex and reproduction.

Don't emphasise death as the worst
thing about AIDS. Although death is
a very real threat to street children
(they live violent and dangerous
lives), they are more concerned with
day-to-day survival. Ana Filgueiras,
a project worker in Brazil, suggests:
'If you tell them AIDS makes you
very weak, that's something they're
afraid of. They know that when
they're weak, they can't survive on
the street.

Above all, don't over-publicise the
issue of street children being a 'risk
group' for HIV infection/AIDS. This
will only increase discrimination
against them.

Action magazine on AIDS

The environmental health magazine, Action, is distributed to
11,500 primary and secondary schools in Botswana, Zambia and
Zimbabwe. It has 16 pages of information and ideas, cartoons,
stories and competitions, on subjects ranging from water and
health to population, wildlife, and tree-planting. Published with
a teacher's insert, it reaches an estimated one million children
aged between ten and fourteen years. Last year the Action
team, based in Zimbabwe, decided to produce an issue on
AIDS. Steve Murray describes planning this issue.

In early 1989 government policy meant awareness workshops, and
that it was difficult to get accurate knowledge, attitude and practice
information on the number of AIDS surveys carried out amongst pupils
deaths or estimated levels of HIV and teachers.
infection in Zimbabwe. So we
approached planning an Action issue Planning the message
on AIDS with some caution. We also knew that to reach more children we
had to encourage more teacher
take up the issue. We tried to do this
through a special 16-page pull out
section for teachers, giving
background information on AIDS education.

Where did we start?
As with all Action issues, we started by
holding discussions with a range of
local groups already involved in the
subject concerned, in this case AIDS.
These included the AIDS Counselling
Trust (Harare), the Department of
Community Medicine at the University
of Zimbabwe, the National AIDS
Control Programme and curriculum
developers in the ministries of health
and education in the countries concerned.
An editorial advisory team was
formed with representatives from
ministries and non-government
organisations working in AIDS
management, education and counselling. To plan the issue, we also used
information gained from earlier AIDS awareness workshop, and knowledge, attitude
and practise surveys carried out amongst pupils and teachers.

Planning the message
The team identified areas of public misconception about AIDS/HIV and
tried to ensure that the magazine clarified these.

They Included:

Figure one

confusion between AIDS and HIV and how HIV infection leads AIDS

the belief that only certain groups of people e.g. prostitutes, get
AIDS;

widespread denial that AIDS was a new or serious problem;

lack of accurate knowledge about AIDS/HIV among teachers.

The magazine tried to combat the fear,
stigma and panic associated with
AIDS, emphasising the supporting role
which the extended family and the
community can play in the care of people
with AIDS/HIV.

Figure two

Making the message fun
The magazine had to provide accurate
information in an entertaining way, to
help teachers and pupils think
positively about how they could stop
themselves becoming infected with
HIV. Lots of comic strips (some in colour) and humorous illustrations
were used. The section titled 'You
can't get AIDS by touching' uses
cartoons to expose false beliefs, such
as 'AIDS is a disease caused by a spell
put on an unfaithful woman by her
jealous partner'. 'A family crisis' is a
short, comic strip story set in a
township family home, involving a
young couple whose first baby,
George, dies from AIDS. The story
deals with reactions of the extended
family, while its sequel 'Let Love Continue'
(see figures 1 and 2) looks at the
wider community response. The
stories relating to the death of baby
George reflect the fact that in southern
and central Africa, infant mortality from
AIDS is rising; around 20 per cent of
AIDS cases are in the 0-4 years age
group.

Pullout teachers' pages
The following is a summary of
contents:

Ways of approaching AIDS education,
including basic facts and
figures about AIDS.

Activities for pupils based on the
magazine including summary of the
main teaching points.

Instructions for playing educational
games e.g. board game played with
dice. Players complete one circuit of
the board, and may land on 'discussion'
or 'question' squares. Two
packs of discussion/question cards
include subjects like: As long as you
stay away from people in the city,
you won't catch AIDS. What is the
most common way people get
infected with HIV in our country?
There are fifteen printed cut-out
discussion cards and nine question
cards (with answers) ready to use.

Home from home

Helping children on the streets of BogotŠ
Every Tuesday and Friday night, from 8.00 pm until 6.00 am, a doctor and three volunteers from the Colombian
Red Cross drive around the streets of BogotŠ in a van
installed with a solar heated shower room and small clinic.
The van stops in areas where groups of street children live.
Rosa Gaviria talked to the staff and children involved.

The project's medical doctor, Dr Castro,
explains: 'The children get to
know the van's regular timetable.
Because it is an area of the city which
doesn't involve the police or the authorities,
little by little the children
come to trust us. Some just come for
a shower, others because they need
treatment for illness or injury; or
some just want to chat about their
problems.'

Forty per cent of the population of
Colombia live in absolute poverty.
This is the underlying cause of the
dreadful problems faced by children
living on the streets; problems which
include violence, drug addiction and
sexual exploitation. Some children
sleep in the appalling conditions of
the sewers which run under the
wealthy hotel and banking district to
escape the worst of the violence,
such as bombs and 'social clean-ups'.
These clean-ups are carried out
by private death squads who murder
street children, beggars, drug
addicts, prostitutes and homosexuals
in selected areas. Such killings
accounted for over 400 deaths in
1989.
Drug
use

The
children commonly take drugs to suppress
feelings of fear, hunger and cold.
Fourteen year old Elena, who
lived on the streets for seven years, explains:
'We used drugs a lot to stop thinking
about the hunger, especially
at night. It's difficult to live on the
streets and not take them. You're in the
park alone and miserable, you see
some kids smoking and sniffing and they
invite you over - they're nice to
you. At least at the start.'

Youngsters often begin with sniffing glue,
or 'boxer' as it is known, and then
start adding aspirin and banana peel
to strengthen its effects. They siphon
off petrol from cars and inhale that.
These habits create respiratory, kidney
and eye problems. Elena added: 'After
we had been sniffing glue for five or six
years, we got really bad chests and
blood started coming out of our noses.'

STDs and child-size condoms
When living in such. conditions, sex
among friends provides a source of
comfort to the children, or a source of
cash from adult clients. Adult exploitation is commonplace. Dr Castro
explains: 'Some adults specialise in
developing links with the children in
order to rent them out for sex. They
take children off the street, wash them,
give them smart clothes for the night
and then deliver them to a client. The
child gets paid only a tiny proportion
of the fee and is then returned to the
streets.'

Not surprisingly, sexually transmitted
diseases (STDs) among the
children are very common. HIV/AIDS
has also been identified as a problem,
but it is almost impossible to find out
the rate of HIV infection as children
resist having blood tests of any kind.
Attempts at enforced testing by state
health authorities have caused an out-cry.
All Red Cross programmes which
involve blood tests are strictly based
on the principle of voluntary consent.
In addition to providing free medical
treatment from the van, Red Cross
staff carry out preventative health
education including the promotion of
safer sexual behaviour. But, as Dr
Castro points out: 'One of the main
problems in trying to prevent the
spread of STDs is that child-size condoms
are not available. No child is
going to use a condom if it's always
slipping off.'

Leaving the streets
During their night's work, the project
staff try to refer some of the children
to other organisations which can provide
a home or more permanent care.
'The children have started advising the
staff which of them may want to try leaving the streets. But normally it is
only the most recent arrivals who can
be referred, as they have not become
so "addicted" to street life.'
One such organisation is the
Foundation for the Children of the
Andes, set up and run by a Colombian
businessman. The Foundation runs
three houses providing basic
education, practical training, re-creational
activities and medical care.
One of the main objectives is to try and
show children what family life can be
like. Elena, who now lives at the
Foundation explains: 'On the streets
nobody cares and you get abused. But
here they look after you like they were
your own parents.' A fundamental
principle of the house is freedom; the
children can leave whenever they
want. Not surprisingly, few of them do - at least, not until they have better
life choices in front of them.

Neurological problems associated with HIV are common. In western studies,
roughly ten per cent of patients present
with neurological symptoms and signs,
and up to three-quarters of AIDS
patients have nervous system (NS)
abnormalities detected at autopsy. In
the parts of Africa where HIV is
endemic, the prevalence of HIV-associated
neurological disorders is
largely unknown, but is a recognised
problem. Neurological diseases related to HIV can be broadly grouped
into two categories: (1) direct effects of
HIV itself on the nervous system, and
(2) indirect effects of HIV, where
immunosuppression leads to opportunistic infections and tumours.

Direct effect of HIV
Some of the effects of HIV occur early
in the course of the disease. Many
people (perhaps the majority) have
asymptomatic NS infections, the only
signs being in the cerebrospinal fluid (CSF). The abnormalities include
a raised CSF protein and a moderate
increase in lymphocytes. A few people
develop acute neurological symptoms
and signs at the time of seroconversion.
This may take the form of
acute confusional states (delirium), seizure,
acute aseptic meningitis,
encephalitis or encephalomyelitis.
There may also be associated abnormalities in the peripheral nervous
system. Usually patients recover over the course of a few weeks with no obvious clinical after effects.

At a later stage, some patients
may develop neurological problems before they develop AIDS (the final
stage in HIV disease). These may
consist of peripheral neuropathies
(sometimes painful) and isolated
peripheral nerve palsies. Occasionally patients develop an
ascending paralysis, like Guillan-Barre
syndrome, with weakness
initially in the lower limbs that
subsequently develops in the upper
limbs. Paralysis of the respiratory
muscles is life-threatening.
Sometimes a transverse myelitis
occurs, with paralysis of the lower
limbs as well as marked sensory
losses. This can mimic spinal cord
compression.

AIDS Dementia Complex Perhaps
the commonest NS problem, known
as the AIDS Dementia Complex
(ADC), occurs in the later stages of
HIV infection, usually after the
patient has been diagnosed with
AIDS. The disorder is characterised
by cognitive, motor and behavioural abnormalities. Patients may show
slowness of thinking and have
difficulties with concentration and
memory and may eventually become quite apathetic. The appearance of
acute confusional states (delirium) is
also possible. Early motor problems
include poor balance and co-ordination;
the patient may note that
s/he is becoming clumsy. More
rarely, patients develop an acute
psychosis and can become manic.
However, as ADC advances, patients
are listless and apparently indifferent
to their illness, eventually becoming
doubly incontinent (urinary and
bowel incontinence) and completely
dependent on the care of others.

Vacuolar myelopathy Sometimes
patients develop spinal cord disease known as vacuolar myelopathy. This
usually presents with inco-ordination
and difficulty walking. Later there are
disturbances of bladder and bowel.
This condition is often followed by the
development of ADC.

As noted above, the early
NS problems caused by HIV usually
improve spontaneously. The late
manifestations, particularly ADC, may remain stable for a few months but usually progressively worsen.
Zidovudine (cf. WHO Report issue 8, pp 2-3) is the only drug that
appears to be useful for these
problems, and then only for a limited
time. Humane care and support for
these chronically ill patients is often
best in the home with the support of
the family rather than in hospital.

Explanation of scientific terms
ataxia: an inability to co-ordinate voluntary muscular movement,
symptomatic of nervous disorder.encephalitis: inflammation of the brain, causing
confusion, limb weakening, or even coma.encephalomyelitis: concurrent inflammation of the
brain and spinal cord, causing malfunction of thought,
consciousness and use of limbs.focal neurological signs: e.g. localised
disturbances such as a stroke or hemiplegia resulting from damage
to specific areas in the brain.hemiplegia: paralysis of one side of the body, or
part of it, resulting from injury to the motor centres of the
brain.meningitis: inflammation of the membranes surrounding the brain
and spinal cord (aseptic; not associated with bacterial
infection).myelitis: inflammation on the spinal cord or bone
marrow (transverse myelitis: inflammation across one
section, rather than lengthwise)nerve palsies: damage to specific peripheral nerves
leading to specific muscle weakness.
neuropathies: abnormal and usually degenerative state of the
nervous system or nerves.peripheral nervous system: the part of the nervous
system outside the central and autonomic nervous system e.g. the femoral
nerve.psychosis: serious mental illness, characterised by
lost contact with reality, often with hallucinations or delusions.retinitis: inflammation of the retina which may lead
blindness

The nervous system is prone to a
variety of opportunistic infections as
the individual's immune system
declines. The most important and the
most common infections are cryptococcal meningitis and toxoplasma
encephalitis.
Cryptococcal meningitis This usually
presents with a headache and fever
and may therefore mimic malaria.
Usually there are subtle neurological
signs, such as mild neck stiffness,
ataxia and occasional cranial nerve palsies. Diagnosis is by examination of
the cerebrospinal fluid; while there
may be only a few white blood cells
and the biochemistry may be normal,
India ink staining will reveal the cryptococci.
Treatment involves the use of
systemic antifungal drugs, such as
amphotericin B (0.3mg/kg/day, I.V.)
fluconazole (400mg/day) or
itraconazole (200mg/day). Therapy
should be continued for at least six
weeks.

Toxoplasmosis This usually presents
with focal neurological signs, often
mild hemiplegia, due to a cerebral
abscess. Diagnosis is difficult, even
with sophisticated X-ray facilities, and
as the only sure way of making the
diagnosis is by a brain biopsy, most
clinicians use a therapeutic trial of anti-toxoplasmosis
treatment if they
suspect the diagnosis. Initial treatment
is with a combination of pyrimethamine
(50-75mg/day) and sulphadiazine (4-6
grams/day) in divided doses, usually
for at least three weeks. Other
combinations that can be used are
pyrimethamine (same dose) and
dapsone (100mg/day), and pyrimethamine
and clindamycin (300mg
four times per day). Cryptococcosis
and toxoplasmosis, like other opportunistic
infections in AIDS, need to be
suppressed by some form of
maintenance therapy that is continued
indefinitely after the initial treatment of
the acute illness. This usually involves
the administration of the same drugs
used for acute treatment, but at lower
doses.

Other opportunistic infections can
also cause NS problems. Tuberculosis,
candida and herpes simplex
can all lead to focal cerebral disease.
Cytomegalovirus and herpes zoster
may lead to peripheral neuropathies or
to a transverse myelitis. It should also
be remembered that cytomegalovirus
causes retinitis.
Tumours and progressive multifocal
leukoencephalopathy (PML) Focal
neurological problems, usually hemiplegias, may result from tumours of the brain, the commonest being a
lymphoma. Very rarely, Kaposi's sarcoma
occurs in the brain. These
tumours can only be reliably
diagnosed by brain biopsy. They
respond poorly to treatment and carry
a bad prognosis.

Another condition seen occasionally
is progressive multifocal leukoencephalopathy (PML). This is a slowly
progressive and fatal disease,
probably caused by a papovavirus,
that presents with focal neurological
signs, e.g. hemiplegias, or a stroke.

Summary
The spectrum of NS disease
associated with HIV is quite broad.
The acute symptoms may improve
spontaneously, but many of the
manifestations associated with later
stages of HIV infection have no
treatment and a poor outlook.
However, prompt diagnosis of some of
the opportunistic infections, especially
cryptococcal meningitis and toxoplasmosis,
is important, as these
usually respond well to specific
therapy.
Dr Chris Conlon, John Radcliffe
Hospital, Oxford, UK. Dr Conlon has
worked for a number of years in Zambia,
managing AIDS patients at the
University Teaching Hospital, Lusaka.

Letters

Are condoms safe?
In my country, efforts are made to
reduce the spread of HIV/AIDS by
counselling. People are encouraged to
use condoms as a safe way of avoiding
infection.

After ejaculation the penis goes
limp, and there is back pressure within
the condom itself. This will make the
semen flow out. If the man is HIV
positive, will he not infect the woman
with whom he has a sexual relationship?
We must find safer ways rather
than condoms!
Nuru Percival Kaoza, Ludewa
District Hospital, PO Box 3,
Ludewa, Iringa, Tanzania.

Ed. Condoms, when PROPERLY used,
are relatively safe method of protection
against sexually transmitted
diseases (including HIV). Proper use
of condoms includes: putting on the
condom as soon as the penis is hard
and before it touches the other person's genitals; withdrawing the
penis immediately after ejaculation
while it is still hard, holding the condom
in place; only using water-based
lubricants (if used at all) as some
lubricants, such as Vaseline, weaken
the rubber and may cause the condom
to break; and disposing of the condom
safely. Since all condoms may break
or split, people should realise that they
are still taking a risk if they have
penetrative sex; it is much safer to use
two condoms at once - one on top of
the other.

Routes of transmission of HIV
I would like to ask two questions on
HIV transmission:

If food is contaminated with the
blood of an HIV infected person, would
the person who ate the food be
infected with HIV?

You said in AIDS Action issue 1 that
infected mothers can pass the virus on
to their unborn children, either during pregnancy (through the placenta) or
during birth. Then you said the spread
of HIV can be prevented from mother
to child. Could you tell me how it is
prevented?

S Bangura, Njala University College,
Freetown, Sierra Leone.

Ed. The answer to the first question is
no. Unless the food is obviously covered
in fresh blood (in which case you
wouldn't eat it) the chances are that there
would not be any active virus on the food.
HIV is a fragile virus and needs to be
inside a living cell to survive for any
length of time. Obviously, cooking will
destroy the virus, as it is sensitive to heat.

The risk of an HIV positive mother
transmitting the virus to her unborn child
varies between 20-40 per cent in different
parts of the world (see AIDS action, issue
9). The only way of preventing
transmission from mother to child is
by preventing initial infection in the
mother, through education and safe
blood supplies.

Publications

GeneralStreet Children of Cali by Lewis Aptekar, published by Duke University
Press. (USA) ISBN 0-8223-0834-7. Best
book published on street children, their
lives and mental health. It is based on
well conducted research. Available
through booksellers. Price: £30.80.

In the Streets: Working Street
Children of Asuncion, published by
UNICEF, Regional Office for Latin
America, BogotŠ, Colombia. A
thorough analysis of the real conditions of life for children living on the
streets of Asuncion, Paraguay.

Street Youth and AIDS, published by
the Federal Centre for AIDS, Health
Protection Branch, Health and Welfare
Canada, 301 Elgin St, Ottawa,
Canada, K1A OL2. An excellent study,
based on good research.

An experience with street children,
by Fabio Dallape, available from the
Undugu Society of Kenya, P O Box
40417, Nairobi, Kenya.

Combatting Child Labour, by
Bequele and Boyden, published by the
International Labour Office, CH 1211
Geneva 22, Switzerland. Provides an
overview of alternative approaches to
working with street children. Price:
US$23 approx.

Prostitution
An international directory of projects
for child victims of prostitution will be
published in French, English and
Spanish, early 1991 by the International
Catholic Child Bureau, 65 rue
de Lausanne, Geneva, Switzerland. It
will contain details of health and sex
education activities.

Human rights
AIDS and street children are human
rights issues. Details of children's
human rights issues can be obtained
from: Defence for Children International (DCI), Case Postale 88, CH 1211
Geneva 20, Switzerland. DCI publishes
Children's Rights Monitor, a quarterly
publication in French, English and
Spanish. There is likely to be a local
DCI organisation in your country. DCI
Geneva can supply details.

AIDS education Help with changing health workers'
attitudes towards AIDS and sex education is found in Working with Uncertainty
by Hilary Dixon and Peter
Gordon, available from: Cambridge
Health Promotion and AIDS Service Training Department, Addenbrooke's
Hospital, Hills Road, Cambridge CB2
200, UK (price around £13.00. 2nd
edition). Another useful booklet on this
area is Talking AIDS: a guide for community
work by Tony Klouda and
Gill Gordon, available from TALC, PO
Box 49, 5t Albans, Herts, AL 1 4AX,
UK. (price £1.25).

Sources of information

You can find out more about the work of
many other researchers and street
workers, including details of organisations
run by children themselves, by contacting
the international database on
street children at: Streetwise International,
The Old Maltings, Green Lane,
Linton, Cambridge CB1 6JT, UK.

Another organisation to contact is
Street Kids International (SKI), 56 The
Esplanade, Suite 202, Toronto M5E 1A7,
Canada. Based in Canada, SKI started
its activities with street children in Khartoum.
See educational materials below.

Educational materials

Street Kids International (see above)
has produced an animated cartoon
video on AIDS called Survivors, for
use with street children. It features
a Karate street hero and tells the
story of two boys living on the street,
one of whom becomes infected with
HIV and dies of AIDS. SKI have also
produced an educator's manual to
accompany this video, entitled The
Karate Kids. Both video and manual
are available from Street Kids International.
Other language editions
are available.

The Child-to-child Programme at the
Institute of Child Health, 30 Guilford
St, London WC1, UK, have produced
activity worksheets to help children
make their own health decisions
such as Smoking: Think for Yourself
and Deadly Habits (on drug use,
smoking and STDs), Available from:
TALC, PO Box 49, St Albans, Herts,
AL1 4AX, UK,

Free fact sheets on Street children and AIDS/HIV and Streetgirls available
from: Childhope USA, 333 East 38th
St, New York, NY 10015, USA.

Conference

Policies in Solidarity
Conference for AIDS related non government organisation (NGOs).
There is the second international conference on NGOs working on
AIDS and is the successor to 'Opportunities for Solidarity' a
three day pre-conference on AIDS held in Montreal in June 1989.
Policies for Solidarity is co-organised by the National
Minority AIDS council (USA), and Le Comite Frances SIDA.
Registration fee: US$150.00. For conference programme and
registration details contact: Conference Secretariat, 41 Rue du
Docteur Heulin 75017, Paris, France.
Tel. 33.1.42288280. Fax:
33.1.42262693.

WHO Report -
Global Programme on AIDS

Using audio visuals in health education

Simone Chaze, consultant to the Global Programme on AIDS,
provides some practical hints on how to get the best out of using
film and video in health education.

Before using film or video for health
education, consider the following:

Is the intended audience used to
watching films? Does the community
have more traditional, and
possibly more effective, ways of communicating e.g. through dance, theatre or puppets?

Do not assume that video film is
always the best way of educating people.

Are you showing the right film?
Always watch the film yourself before
you show it to a group of others. Make
sure it is relevant for the audience and
for their culture. Cultural differences
can mean that people do not understand
the message properly. Do not
forget that the impact of the film comes
primarily from the visual style, rather
than the content of the verbal
message. The tone of the film (whether
it is terrifying, aggressive or intellectual)
will also affect the film's impact.
You need to bear in mind that those watching a film receive its messages,
impressions and information at several
different levels:

content of the script is the
vocabulary appropriate and
understandable? Do the tone,
music and spoken messages used
go well together or are they disjointed?

visual images are they acceptable
and understandable to the
audience? If you are in any doubt,
try a test viewing with a few people.

The length of the film is an important
consideration. About 10-15 minutes is
the maximum attention span. Beyond
30 minutes, it is difficult to keep the
interest and attention of the audience.

Do you have the right equipment?

Are the specifications of the video-cassette
and the video recorder
compatible? For example, you can-not
use a Betamax cassette with a
VHS machine.

Is the video recorder available for
use on the required day at the
required time?

Can the room used for video showing
be easily darkened?

Is the cable long enough to position
the video equipment so that
everyone can see and hear clearly?

Check the local availability of electricity.

One TV screen is sufficient for a small
audience up to about 30 people;
several TV screens can be synchronized
for a simultaneous showing
in a large room. But for most large
audiences (more than 50 people) consider
using a cine-film. If you do not
have a portable film screen, use a
blank wall.

Presenting the film
Be brief. Talk about the film's length,
its origins, theme and subject matter.
Say why you are showing it, and
how it is linked to the objectives
of the meeting or the training course.
Where appropriate, mention the
aspects of the film you want particularly
to be noted. Run through
some of the film's important points. An
audience not used to audiovisual
technology could be distracted by the
technology itself.

The intention of showing a film is not
only to get a message across; you are
also trying to provoke verbal and
emotional reactions which will open
discussion. The film projection must
therefore be arranged to allow time for
discussion. Never stifle discussion by
showing the film and then immediately
closing the meeting/session.

Presenting information
You can use videos to complement
or illustrate a discussion, by showing
a film that gives information on
a specific topic, such as the AIDS virus,
and how it works. This may
include the testimony of someone
infected with AIDS, for example.
After showing the film give the
audience time to express their emotions and give spontaneous reactions.
Respect their silence.
Then get the discussion going with
an open question, such as: 'Now that
you've seen the film, how easy do
you think it is to become infected with
HIV?' Make sure the audience has
understood the film's message, and
see if you need to clarify or give more
information. Then the discussion can
be broadened to cover aspects which
directly affect the audience.

As a teaching aid
The video film is an excellent teaching aid.
You can flick forwards and backwards,
stop the film for discussion,
analyse the script and the visual images.

The course leader should make a
guide for him/herself to steer the group through the analysis; cutting the film
into sections, stopping the film when
it seems necessary. The leader must
know the film well and guide the participants
without losing sight of the
training objectives.
Training teachers
Video film can be used for practical
exercises and to experiment with the
effectiveness of teaching methods. For example,
you could ask the trainee teacher to work alone on a section of the
film; put together a guide for
discussion; list the elements which
s/he wants to highlight and give
reasons; and show how s/he would
lead the discussion. You could invite
a trainee to adapt use of the film for
different target audiences, and to identify
sections to be cut or added. A film
can be used to organise other teaching
sessions by adapting it into a sketch,
cartoon or play.

Evaluating AIDS health promotion

Nina Ferencic, from the Health Promotion Unit of the Global
Programme on AIDS, gives some practical guidelines on approaching the
evaluation of health of health promotion programmes.

It has been stated many times: health
promotion is the key to preventing the
further spread of HIV. And it can
lessen the emotional, social and
economic impact of the epidemic. But
how can we be sure of this? The
answer lies in effective evaluation.
Evaluation must be an integral part of
health promotion programmes, in
order to assess their efficiency and
effectiveness.
What is health promotion?
Health promotion aims to change the
behaviour of individuals and society
with the aim of improving health. Effective
AIDS health promotion combines
what is known about AIDS with communication,
information and education
strategies designed to change
behaviour, create a supportive
environment for that behaviour
change, help stir public policies and
secure the social services and
resources necessary for positive
change. Health promotion relies on
many different channels of information
and education to achieve a sustained
impact on public health.
What is evaluation?
Evaluation is a valuable tool for
programme planning and decision making. In order to be effective, AIDS
health promotion programmes should
be based on a set of informed
decisions, resulting from ongoing
evaluation. This implies two things.
One, that programmes should be flexible
enough to adapt to new insights
and recommendations arising from
evaluation research; and two, that
evaluation must provide timely feedback
to programme decision-making in
a straightforward and appropriate
manner.

One of the main purposes of evaluation
is to answer practical questions
about programme functioning and effectiveness,
which can help to
reorganise the programme if
necessary. Evaluation should not only
reveal whether the programme is
achieving the desired results, but
might also question the programme
aims.
Evaluation should also be applicable
to day-to-day decision making, to help
bring about changes that are
necessary. There is no point knowing
about the impact of a programme once
it is over, when the information cannot
be used to improve it. Although most
programmes would benefit from
evaluation, there are often limited
financial and personnel resources
available to carry it out.

Approaching evaluation
The decision to evaluate is usually a
joint one made by a programme and
its participants, together with a
ministry, department, organisation or
funding agency. The objectives and expectations of
the evaluation need to be clearly
agreed by all those concerned. Before
evaluation begins it is also necessary
to come to an agreement about what
the current programme objectives are,
and which objectives are to be
evaluated.

Avoiding suspicionAn evaluation process can be resented
or viewed as threatening by programme
staff, who may feel that the
results will be used to criticise their
work. To avoid misunderstanding and
suspicion, evaluators must understand the details, aims and limitations of the
programme itself, and the difficulties
involved in its current functioning.
Evaluators must also clearly explain
the purpose and methods of the
evaluation to programme staff, and
how the information gained will be
used. Remember, it is usually the programme
which is to be evaluated, not
the programme staff!

Information gathering
Most programmes require some basic
information about their aims, such as:
who are the health messages aimed at? Are the messages understood?
Given that there are often limited
resources, it makes sense to collect
information on aspects of the programme
which are most likely to
explain programme success or failure.

Exposure to information and comprehension
of the message are two
of the most important aspects of any
health promotion programme. These
are the aspects to look at first when
assessing the programme.

Assessing outreach
Assessing whether the health promotion
programme is reaching the
desired audience is the most important thing to discover. If only a small
proportion of the target audience is
being reached by a programme, how
can it be expected to have any significant impact?

Ask the following questions:

Is the programme being
implemented as planned? e.g.
have posters stayed in a
warehouse, or have they been
properly distributed?

Who was exposed to which
messages?

What channels of communication
were used? e.g. mass media,
institutions or interpersonal communication.

How often? e.g. if radio programmes
were made, how often
were they aired?

Specific research questions will vary from programme to programme
depending on which channels of
information and education are used.

Assessing knowledge, attitudes and practice
Evaluation should also collect information on behavioural change. Are those
who are exposed to (and understand)
health promotion messages likely to
adopt the recommended practices
more readily than those who are not?
Changes in behaviour are always
harder to achieve (and document)
than changes in attitude or knowledge.
While behaviour change is an
essential indicator of the success of
a programme, it is not the only
indicator. Measuring changes in
knowledge and attitude is also important since these may later lead to
changes in practice.

Assessing comprehension of the message
Although people may have seen or heard health messages, they do not
necessarily understand them. An
evaluation must find out whether people
in the target audience understand the
message and see it as relevant to them
individually. For example, do they
understand that they have to use a new
condom every time they have sexual
intercourse? Do they understand where
they can obtain condoms? Do they
understand what condoms are?

Changes in knowledge and attitude
may show that an information campaign
has had immediate effect; changes in
practice, however, may be impeded by
factors beyond the control of the programme - such as poor health services,
inadequate supplies of condoms, or
other factors. It is therefore essential that
evaluation results are interpreted, keeping
in mind the broader social, cultural
and economic context.

Carrying out the evaluation
In addition to deciding what to evaluate,
it is necessary to decide how to carry out
the evaluation. A number of designs
and methods can be used, such as
carrying out epidemiological surveys,
face-to-face interviews, focus group
discussions; taping and analysing
workshops; analysis of existing programme
information (records, reports,
diaries); measuring frequency and scope of publicised health messages;
asking verbal or written questions. A
decision has to be made about what
level or complexity of evaluation is
required:

How complex is the research method
to be?

How will the results be analysed? e.g.
are computers available?

How big a sample should be taken?

How detailed should a questionnaire
be?

More ambitious and large-scale
evaluation activities are more expensive,
since they involve more time (and
often more material resources) to carry
out. The choice of evaluation technique
will depend on the time, expertise,
personnel and financial resources
available. However, the most
sophisticated procedures are not
necessarily the best. It is more important
to have an appropriate quality of
evaluation, adjusted to the purpose of
the evaluation and the level of
confidence that the evaluators need to
have in the results. In addition,
evaluators should be cautious in the
use of their results: such as avoiding
the assumption that changes in
behaviour are caused only by the
existence of the programme, or that a
small-scale evaluation applies to a
wider programme or group of people.

In general, evaluation of health
promotion programmes should be kept
simple and to the point, with the
primary objective of improving the
health promotion activities concerned.

Educating youth

The following is a brief guide to
research and educational activities
with youngsters in and out of school, coordinated by the Global Programme
on AIDS:

In school

In co-operation with UNESCO, pilot
health promotion and educational
projects have started in Sierra Leone, Ethiopia, Jamaica, Tanzania, Mauritius and the Western Pacific.
The overall objective is to develop and
evaluate strategies for effective health
promotion in schools, and to
encourage collaborative work among
ministries, non-government organisations (NGOs), youth and teacher
organisations. A WHO/UNESCO
Guide for School Health Education to
Prevent AIDS and Sexually Transmitted
Diseases will be available
shortly from WHO/GPA (address
below).

A series of international and regional
meetings have been held, including:
regional seminar in Bangkok,
February 1990, for Asia and the
Pacific, co-organised with UNESCO,
which provided the first occasion for
top officials from ministries of health
and education to meet and plan
regional and national strategies;
World Consultation of Teachers on
AIDS education in Schools held in
Paris, April 1990, co-organised with the International Labour Organisation; regional meeting in Ethiopia in
May, to outline the development of a
school curriculum and teacher-training
programme for Africa.

Out of school
The emphasis at present is on promoting
systematic, research-based approaches
to health promotion.

WHO/GPA is collecting and reviewing
information about the experiences of
existing youth and adolescent programmes
around the world. A guide for setting up health promotion programmes
will be developed by the
end of 1991, as well as a series of programme
modules. Prototype training
materials will be developed and field-tested
for use in institutional and non-institutional
settings.

Research and evaluation activities
will be carried out, with the aim of
assisting health educators to make
the best use of their own research into
developing effective health promotion
messages, and using more effective
channels of communication. As part
of these planned activities, a
Technical Working Group on reaching
and communicating with youth met in
August 1990 in Geneva.

A number of other activities have also
taken place, for example, international
training workshops for youth leaders
organised jointly by WHO with the
World Assembly of Youth in
Cameroon and Barbados, and
knowledge, attitudes and practice (KAP) surveys among young people conducted in Nigeria, Cyprus, United
Kingdom and elsewhere.

Papers from meetings and reports of
KAP surveys available on request from
WHO/GPA.

World AIDS Day 1990 focus on women
Women and AIDS is to be the theme for
World AIDS Day 1990. Dr Nakajima
(Director General of WHO) said this
focus will reflect the increasing impact
of AIDS on women, as well as the crucial
role that women play in preventing infection
with the human immunodeficiency
virus (HIV), and caring for people
infected with HIV or who have AIDS. This
event will be undertaken within the
broader framework of women, health
and development, particularly at the
country level.
World AIDS Day aims to:

heighten awareness about the risk of
HIV infection and AIDS, especially in
women;

highlight the impact of HIV/AIDS on
women around the world including
medical, social and psychological

aspects;

strengthen AIDS prevention activities
and programmes at all levels of
society, especially as they concern
women;

promote respect and care for all HIV
infected people and people with AIDS

contribute to a lasting dialogue, sustained activity and long term
commitment
among all people in countries
around the world.

This annual event will also highlight the link between women's status within
society and opportunities open to them for behavioural changes, and draw attention to the special concerns related
to HIV and pregnancy, childbirth and
raising children.

WHO estimates that at least eight to ten
million people worldwide are now infected
with HIV, and that approximately one third
are women. Increases in the rate of HIV
infection reflect the growing incidence of
heterosexual transmission around the
world. As a result, there will be an increasing rate of HIV infection, AIDS cases and
deaths among women and children in the
1990s. During the 1980s, the HIV/AIDS
pandemic caused an estimated 500,000
cases of AIDS in women and children,
most of which have been unrecognised.
During the 1990s, WHO estimates that
the pandemic will kill an additional three
million or more women and children. In
addition, more than ten million uninfected
children will be orphaned, because their
HIV infected mothers and fathers will
have died from AIDS.

Millions of people around the world
participated in the second annual World
AIDS Day on 1 December 1989 which
focused on young people and AIDS. With
events held in over 160 countries and at
WHO offices around the world, it was the
largest global day of information and
activities against HIV/AIDS ever held.
WHO will provide the following
materials for World AIDS Day 1990:

World AIDS Day newsletters (containing
ideas and guidelines for planning events)

Special World AIDS Day poster and
Action Kit

Special issue of World Health
Magazine on Women and AIDS

Media materials on Women and AIDS
and advice on working with the media

If you are not already on the WHO World
AIDS Day mailing list, contact: World
Health Organization, GPA/PIO, 1211
Geneva 27, Switzerland.

Top left photograph, showing a close-up of a
European patient with AIDS, depicts skin lesions
caused by molluscum contagiosum and not (as
indicated) shingles.

Photograph used to illustrate persistent
generalised lymphadenopathy (PGL): a second arrow should have indicated symmetrical
enlargement of the lymph glands on both sides of the patient's neck (in the photograph, the right
side is less pronounced). Lumps associated with PGL are usually symmetrical, and the Glands
are firm, discrete and not tender. They are not usually very large and may be difficult
to see. A lymphoma should be suspected where the lymph node
enlargement is very pronounced, painful and asymmetrical.

Any questions about the content of the WHO Report should be sent to:
WHO/GPA, 20 Avenue Appia, 1211 Geneva 27; Switzerland.

This
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